Comparative Billing Reports

CBR201704
Transitional Care Management (TCM) FAQs

TCM was selected as a CBR due to increased Medicare spending on TCM services over the last three years. Additionally, the Office of Inspector General (OIG) has identified TCM as a problem area. As a result, the OIG is reviewing TCM to determine if these services are being paid according to Medicare guidelines. For more information, select the following link: OIG2017 Work Plan.

The Centers for Medicare & Medicaid Services (CMS) utilizes CBRs as tools to educate providers about correct billing procedures. CBR201704 was created to inform providers about their billing and payment patterns for TCM services. For this report, we reviewed Fee-for-Service Medicare (Original Medicare) claims with Current Procedural Terminology (CPT®) codes 99495 and 99496. Please visit the following website for more information: Comparative Billing Reports.

To choose providers for this CBR, the data team analyzed Medicare Part B claims of providers who billed claims with TCM CPT® codes. Reports were then sent to approximately 6,000 providers identified as having different billing practices than their peers. Providers who did not receive CBR letters can review a sample on our website at the link: CBR201704 Sample CBR.

Does receiving a CBR mean that I am billing my TCM claims incorrectly?

No. Receiving a CBR is indicative that your billing is different; however, it does not mean you are billing incorrectly. The CBR can be used as a way to compare your billing patterns to the peers in your state and the nation. If you have questions and or concerns about your CBR, you may contact the CBR Support Help Desk by telephone at 1-800-771-4430 or by email at CBRSupport@eglobaltech.com.

No. The CBR team does not review claims and medical charts for audit purposes. The CBR is for informational and educational purposes only, and allows providers to check and see how their billing compares to their peers. If interested in resources that may be helpful with setting up an audit process, please visit our CBR website page at the link titled, Self-Audit Help.

TCM covers services for a patient who is transitioning from an inpatient hospital setting to a patient’s community setting (home, domiciliary, rest home, or assisted living). TCM is provided only to a patient who has a medical and/or psychosocial condition that requires the provider to make moderate or high-complexity decisions.

What is the difference between moderate medical decision making and high medical decision making?

Per the CPT® Manual, “Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option.” Medical decision making that is moderate means there are multiple diagnoses, a moderate amount of data for the provider to review and a moderate risk of complications. High medical decision making means there are extensive diagnoses, an extensive amount of data for the provider to review and a high risk of complications.

TCM begins on the day of discharge from an inpatient facility and continues for 29 more days for a total of 30 days. Detailed information about the TCM period is available in the Medicare Learning Network(MLN®) publication at the link titled Transitional Care Management Services.

TCM can be provided by a physician and any of the following non-physician practitioners (NPPs): clinical nurse specialist (CNS), certified nurse-midwife (CNM), nurse practitioner (NP) or physician assistant (PA). Please be aware that NPPs must be legally authorized and qualified to perform the services in the State where they are being provided.

No. Both new and established patients are eligible for TCM services; however, the patient must have a medical and/or psychosocial condition that requires the provider to make medical decisions of moderate or high complexity.

What date should I use as the date of service when filing a TCM claim?

The date of the required face-to-face visit is also the date of service that should be used when submitting a TCM claim. Also, the place of service should correspond to the place of the face-to-face visit. Once the face-to-face visit is performed, you may go ahead and submit the claim; however, according to the Medicare Benefit Policy Manual, “only one TCM visit may be paid per beneficiary for services furnished during that 30 day post-discharge period.” For more information, select the following link: Medicare Benefit Policy Manual, Chapter 13, Section 110.4.

Yes. During the transition from inpatient to the community setting, medication reconciliation is necessary to ensure that the patient’s list of medications is correct. Medication reconciliation must be completed no later than the date of the face-to-face visit. This is often done during the initial contact. Auxiliary staff may document the medications; however, the physician or non-physician practitioner (NPP) must order any changes, additions or deletions.

The face-to-face visit must be performed by a physician or NPP but other services may be furnished “incident to” under general supervision. The auxiliary staff can perform the interactive contact with the patient (within two business days following discharge), as well as non-face-to-face E/M services. A description of non-face-to-face services is found at the link, Transitional Care Management Services.

Can TCM be reported if the patient is readmitted to an inpatient facility during the 30-day period?

Yes. As long as the services are furnished by the practitioner and meet the CPT® code requirements, TCM can be reported even if the patient is readmitted within the 30-day period. Following the second discharge, the provider may also bill for the full 30-day TCM period as long as no other provider has billed for the first discharge.

For this CBR, we selected Medicare Part B claims with CPT® codes 99495 and 99496 for services rendered from January 1, 2016 to December, 2016. The analyses were based on the latest version of claims available from the Integrated Data Repository (IDR) as of April 6, 2017. For information on the IDR, please visit the link titled, CMS Integrated Data Repository (IDR).

The CBR team determined that approximately 62,000 providers had allowed charges for the two CPT® codes covered in this CBR. Of these, 6,000 received CBRs. Those who received CBRs were significantly higher than one of their peer groups on at least one of the measurements studied. They were also above the 75th percentile for allowed charges of $3,500 and the beneficiary count of 17.

Table 1 is titled Transitional Care ManagementCPT®Codes and Abbreviated Descriptions. The first column lists the CPT® Code and the second column provides an abbreviated Description for each code. If you did not receive a CBR and would like to review an example, select the following link: CBR201704 Sample CBR.

Table 2 shows the individual provider’s utilization of each procedure code. It is titled Summary of Your Utilization for Procedure Codes. The first column lists the CPT® Code; the second column shows Allowed Charges; the third column shows Allowed Services; and the last column provides the distinct Beneficiary Count for each procedure code. Also included in the table are Totals for the provider. To see an example, select this link: CBR201704 Sample CBR.

Table 3 is the individual provider’s Percentage of Services without a Corresponding Discharge Record. Discharge records from Medicare Part A were selected if they were billed within 30 days of a TCM service. This percentage was calculated by summing the number of TCM services without a corresponding discharge record, dividing it by the total number of TCM services, and multiplying by 100. In the CBR sample, the mock provider’s rate was 19 percent, the state rate was 22 percent and the national rate was 24 percent. Since this provider’s rate is lower than that of the state and nation, the rate Does Not Exceed the state and the national percentages. To view these percentages for each state and the nation, select the following link: CBR201704 Statistical Debriefing.

How is the mock provider’s rate calculated for percentage of services without a corresponding discharge record?

Using the data from Table 3, the percentage is calculated as the Number of Services without a Corresponding Discharge (13) divided by the Total Number of Services (67), and then multiplied by 100. This results in 19 percent.

Table 4 is the provider’s Percentage of Services Billed with CPT® Code 99496. This code requires medical decision making of high complexity and a face-to-face visit within 7 days of discharge. The analysis is designed to compare each provider’s usage of the higher level TCM code to that of his/her peers. Our sample shows that the mock provider’s value is 64 percent, while the state’s is 49 percent and the national rate is 48 percent. This means the provider’s rate is SignificantlyHigher than the state and the nation. To see the percentages for each state and the nation, please visit the CBR website at CBR201704 Statistical Debriefing.

Table 5 is an analysis of the Percentage of CPT® Code 99495 Billed After 14 Days of Discharge Date. Use of CPT® code 99495 requires medical decision making of at least moderate complexity and a face-to-face visit within 14 days of discharge; and the claim should be billed on the date of the face-to-face visit. This metric provides the percentage of CPT® code 99495 claims that are billed after 14 days of the discharge date. This measure is only calculated on TCM services where a discharge date has been identified within 30 days prior to the TCM service. TCM services where a discharge date has not been identified from the Medicare Part A claims database are excluded from this analysis. Our sample CBR shows that the mock provider’s percentage is 58 percent, the state’s rate is 26 percent and the national rate is 28 percent. This provider’s value is, therefore, Higher than the state’s and Significantly Higher than the nation. To view results for each state and the nation, select the following link: CBR201704 Statistical Debriefing.

This provider’s percentage is calculated as the Number of CPT® 99495 Services Billed After 14 Days of Discharge Date (11) divided by the Total Number of Services Billed with CPT® Code 99495 (19), multiplied by 100, for a result of 54 percent.

Table 6 is titled Percentage of CPT® Code 99496 Billed After 7 Days of Discharge Date. Similar to the analysis displayed in Table 5, this table is an analysis of CPT® code 99496, which requires medical decision making of high complexity and a face-to-face visit within 7 days of discharge. Likewise, TCM services where a discharge date has not been identified from the Medicare Part A claims database are excluded from this analysis. In this example, the provider’s value is 66 percent, the state’s value is 28 percent and the nation’s value is 33 percent. Therefore, this provider’s value is Significantly Higher than both the state and the national peer groups’ values. Results for each state and the nation are found at CBR201704 Statistical Debriefing.

The provider’s percentage in Table 6 is calculated as the Number of CPT® 99496 Services Billed After 7 Days of Discharge Date (23) divided by the Total Number of CPT® 99496 Services (35), and then multiplied by 100, resulting in 66 percent.